Saturday, 2 January 2010

Lessons of the Swine Flu Pandemic in USA

Please note that the fatality rate in USA is twice that in UK becauseUSA didn't use Tamilflu quickly enough.In fact, 30% doctors didn't prescribe Tamilflu to patients that hadbeen admitted to hospitals with flu symptoms.

Even UK hesitated on prescribing Tamilflu causing many unnecessarydeaths unlike Japan that had steadfastly prescribe Tamilflu even forcommon flu that can also kill. The lowest fatality rate of Swine Fluin Japan is testimony of the effectiveness of Tamilflu. I alsowitnessed the effectiveness of Tamilflu when given quickly, i.e. lessthan 48 hours. The later Tamilflu were given, the longer it takes forthe flu symptoms to disappear.

However, it is not over yet in USA. Vaccination rate in USA is lessthan 50% unlike Canada and the peak flu season is not over yet, i.e.late January. Let us see if those who are anti-vaccination can survivelonger.

U.S. Reaction to Swine Flu: Apt and LuckySIGN IN TO RECOMMENDTWITTERSIGN IN TO E-MAILPRINTREPRINTSSHARECLOSE

By DONALD G. McNEIL Jr.Published: January 1, 2010Although it is too early to write the obituary for swine flu, medicalexperts, already assessing how the first pandemic in 40 years has beenhandled, have found that while luck played a part, a series of rapidbut conservative decisions by federal officials worked out better thanmany had dared hope.

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John Amis/Associated PressThe supply of swine flu vaccine was far below expectations, butexperts say the pandemic was still generally well managed.RelatedSigns Swine Flu Wave May Have Peaked in U.S. (November 21, 2009)Times Topics: Swine FluEnlarge This Image

Brendan Smialowski for The New York TimesPublic health officials have been credited with quickly debunkingmisinformation that arose at the height of the pandemic.Enlarge This Image

Béatrice de Géa for The New York TimesThe decision to order vaccine made with a 50-year-old egg technology,rather than experimental methods, was controversial.The outbreak highlighted many national weaknesses: old, slow vaccinetechnology; too much reliance on foreign vaccine factories; some majorhospitals pushed to their limits by a relatively mild epidemic.

But even given those drawbacks, "we did a lot of things right,"concluded Dr. Andrew T. Pavia, chairman of the pandemic flu task forceof the Infectious Diseases Society of America.

Even Dr. Peter Palese, a leading virologist at Mount Sinai MedicalSchool, who can be a harsh critic of public policies he disagreeswith, called the government's overall response "excellent."

About 10,000 people had died by mid-November, the Centers for DiseaseControl and Prevention estimated; the pandemic seems unlikely to reacheven the lower end of a forecast of 30,000 to 90,000 deaths made inAugust by the President's Council of Advisers on Science andTechnology.

The virus and the vaccine cooperated. While the former proved highlytransmissible in children, it was only rarely lethal, remainedsusceptible to drugs and has not thus far mutated into anunpredictable monster. Vaccine supply was a problem, but one smalldose was enough. (By contrast, an experimental avian flu vaccineprotected people only when it was six times as strong.)

For that reason, the relatively cautious decisions by the nation'smedical leadership contained the pandemic with minimal disruption tothe economy.

For example, in the early days, they ignored advice to close theMexican border and pre-emptively shut school systems. They releasedpart of the national Tamiflu stockpile, but did not give it tomillions of healthy people prophylactically, as Britain did. Theyordered vaccine made with a 50-year-old egg technology rather thanexperimental methods. They bought adjuvants — chemical "boosters" —that could have stretched the first 25 million vaccine doses into 100million, but did not use them for fear of triggering a backlash amongAmericans made nervous by the messages of the antivaccine movement.

To alert the public without alarming it, a stream of officials — fromdoctors in the navy blue and scrambled-eggs gold of the Public HealthService to a somber President Obama in the White House — offeredupdates, at least twice a week for months.

It is now clear that this is the least lethal modern pandemic. The fluappears to kill about one of every 2,000 people who get it, Americanresearchers say. (British researchers found half that death rate.) Bycontrast, the Spanish flu of 1918 killed about 50 of every 2,000, andthe 1957 and 1968 pandemics killed about 4 of every 2,000.

The flu has reached more than 200 countries and is still peaking inplaces like Eastern Europe and Russia. Even though there was novaccine yet, it killed fewer than expected during the SouthernHemisphere's winter, June through August.

Officials in the United States conceded that some mistakes were made.

For example, they could have spotted the new virus earlier if therehad been better cooperation with Mexico. In late April, the UnitedStates isolated it in samples from Texas and California just asCanadian officials were testing Mexican ones. The outbreak probablybegan in rural Mexico in January, but was spotted only when thousandsfell ill in late March or early April in Mexico City.

The C.D.C. tests viruses in Southeast Asia, where new flus are usuallyborn. "This time," said Dr. Thomas R. Frieden, the C.D.C. director,"one happened to emerge in a place where we don't have a surveillancesystem."

Also, the government predicted in early summer that it would have 160million vaccine doses by late October. It ended up with less than 30million, leading to a public outcry and Congressional investigations.

"Imagine if they'd managed the expectations better," said Michael T.Osterholm, director of the Center for Infectious Disease Research andPolicy at the University of Minnesota. "If they'd said, 'We won't haveany till December,' and had some in October, they would have lookedlike heroes."

Robin Robinson, chief of vaccine purchasing for the Department ofHealth and Human Services, was the most overly optimistic. In aninterview, Dr. Robinson said he had actually tried to be conservative,assuming that manufacturers would get 1.4 doses per egg, when theytypically got two or more.

Until the eggs could be tested in August, "we didn't know that we hadone of the poorest-producing viruses in the last 50 years," he said.Good batches had 0.6 doses per egg, he said, bad ones had 0.2.

If he had it to do over again, he said, "I'd factor in the worst-casescenario — which was 2009."

Another controversial decision — sending a few early vaccine doses toWall Street firms like Goldman Sachs and Citibank — was more of a badpublic relations move than a bad public health one, experts said. Thatchoice was made by the New York City Health Department, "and we madethe decision not to second-guess local health authorities," KathleenSebelius, secretary of health and human services, said in aninterview.

The government allotted vaccine to states based on population size.Some local health officials had thousands line up in parking lots forshots, some sent teams into schools and some relied on privatedoctors.

Distribution of the vaccine could have been focused more precisely,experts said, directing it to hospitals first, or to doctors treatingchildren and pregnant women, or to cities with big outbreaks.

"I still think sending it out on a per capita basis was the fairestand most equitable way," Ms. Sebelius said.

The early combination of fears about the vaccine and anger overshortages, said Dr. Paul Offit, chief of infectious diseases atChildren Hospital of Philadelphia, reminded him of an old Borscht Beltjoke: "The food at this resort is so terrible," one patron complains."Yes," agrees her companion. "And such small portions!"

One real triumph, several experts said, was how little damagemisinformation did. In 1976, many people refused shots after threeelderly Pittsburgh residents died shortly after getting theirs; ittook the C.D.C. five days to explain that it was just a coincidence.

This time, many rumors arose but were quickly debunked: That thousandshad died in Mexico. That the virus had circulated in the Midwest for adecade, undetected. That it had escaped from a laboratory. Thatseasonal flu shots made catching swine flu more likely. That flu shotsdid not work or caused autism. That the administration would make themmandatory. That Tamiflu resistance was widespread in NorthernCalifornia. That a flu shot had disabled a Washington Redskinscheerleader, or that she was cured by chelation therapy by a doctorassociated with the antivaccine movement. That mutant killer flustrains were circulating in Argentina or Ukraine or North Carolina.

The debunking succeeded, Dr. Osterholm said, "despite the fact thatthere are many fewer reporters who understand medical issues thanthere used to be."

This time, both the C.D.C. and the World Health Organization respondedquickly to almost every rumor. At the epidemic's height, they heldseveral news conferences a week, taking questions by phone from allover the world.

They also invited dozens of reporters to daylong seminars on influenzaat C.D.C. headquarters in Atlanta and to exercises around the countryled by the former anchorman Forrest Sawyer, at which they debated, forexample, whether a miscarriage by one woman after getting a flu shotwas a big scoop or a nonstory.

Remaining to be seen is what effect the pandemic has had on Americans'feelings about vaccines.

Dr. Frieden said he thought a victory over the antivaccine movementhad been scored. Nearly 60 million people have been vaccinated,including many pregnant women and children, with no surge in sideeffects.

John P. Moore, an AIDS researcher at Weill Cornell Medical College,was less sure. Dr. Moore, who spent years fighting AIDS denialism, hascalled skepticism about flu vaccine "an unholy alliance of the leftand right" because it joined the liberal natural-medicine proponentswith anti-big-government conservatives.

"It's hard to say if it hurt or helped," Dr. Moore said, pointing outthat polls still show a large minority of Americans rejecting thevaccine. "As with AIDS, people have to die before others understandthe consequences of ignoring science-based medicine."